Endoscopic Retrograde Cholangiopancreatography Training Research Articles

Gender disparity in hepatobiliary endoscopy training and delivery: Results of a nationwide survey

Abstract There are far fewer female, independent endoscopic retrograde cholangiopancreatography (ERCP) practitioners than men in the UK. This study aimed to explore what lies behind the disparity by examining the current state of training, attitudes, and other factors that may influence trainees’ decision to pursue ERCP training, with a view to identifying modifiable factors.Anonymized responses to an electronic survey distributed to gastroenterology trainees and independent ERCP practitioners in the UK were collected and analyzed.Of 214 respondents 45% were female. Whereas gender distribution in non-hepatobiliary therapeutic endoscopy was balanced, only 29% of ERCP trainees were female. Eighty percent of those who worked less than full time (LTFT) were female, but 32% felt that LTFT was incompatible with ERCP training. Concerningly, one-quarter of female respondents reported that they had been discouraged. It was noted that females are often treated differently within endoscopy units, including by patients. Fifty percent of females indicated that radiation exposure affected their decision to train in ERCP, compared with 22% of males. A question specific to trainers revealed that 95% felt that male gender was associated with increased confidence. In free-text responses, valuable insights into trainees’ personal experiences were provided, and a selection is presented. Finally, strategies to redress the gender imbalance are proposed.Gender disparity in HPB endoscopy exists and is stark. Underlying this are attitudes, assumptions, and environmental factors that will require systemic and sustained correction. Ideas about how to address this challenge need to be explored.

Endoscopic retrograde cholangiopancreatography training using a silicone simulator fabricated using a 3D printing technique (with videos)

Endoscopic retrograde cholangiopancreatography (ERCP) training remains challenging. This study used 3D printing techniques to develop and optimize a portable ERCP training simulator and to implement basic and advanced practical techniques. Subsequently, we aimed to determine whether endoscopy trainees acquired proficiency in ERCP techniques and assess any improvements in their skill levels from using this model. An ERCP training model was generated using 3D printing techniques, including five distinct interchangeable and transparent ampullar–common bile duct (CBD) modules. A prospective study using this model was conducted with ten trainees. The technical success rate and examination times for duodenoscope insertion and biliary cannulation were evaluated. In addition, the successful plastic-stent insertion rate and trainee satisfaction were measured. The success rates for duodenoscopy, cannulation, and plastic stent insertion were 94, 100, and 92%, respectively. The mean satisfaction scores for duodenoscope insertion, cannulation, and plastic stent insertion were 4.4, 4.7, and 4.6 on a 5-point scale, respectively. Five attempts decreased the insertion time (R = − 0.591, P < 0.001) and cannulation time (R = − 0.424, P = 0.002). This ERCP-training silicon model is durable, simulates ERCP techniques easily, and helps trainees improve their ERCP techniques.

Endoscopic retrograde cholangiopancreatography training conditions, results from a pan-European survey: Between vision and reality.

Endoscopic retrograde cholangiopancreatography (ERCP) still has a relatively high complication rate, underscoring the importance of high-quality training. Despite existing guidelines, real-world data on training conditions remain limited. This pan-European survey aims to systematically explore the perceptions surrounding ERCP training. A survey was distributed through the friends of United European Gastroenterology (UEG) Young Talent Group network to physicians working in a UEG member or associated states who regularly performed ERCPs. Of 1035 respondents from 35 countries, 649 were eligible for analysis: 228 trainees, 225 trainers, and 196 individuals who regularly performed ERCP but were neither trainees nor trainers. The mean age was 43years, with 72.1% identifying as male, 27.6% as female, and 0.3% as non-binary. The majority (80.1%) agreed that a structured training regimen is desirable. However, only 13.7% of trainees and 28.4% of trainers reported having such a structured program in their institutions. Most respondents (79.7%) supported the concept of concentrating training in centers meeting specific quality metrics, with 64.1% suggesting a threshold of 200 annual ERCPs as a prerequisite. This threshold revealed that 36.4% of trainees pursued training in lower-volume centers performing <200 ERCPs annually. As many as 70.1% of trainees performed <50 annual ERCPs, whereas only 5.0% of trainers performed <50 ERCPs annually. A low individual trainee caseload (<50 ERCPs annually) was more common in lower-volume centers than in higher-volume centers (82.9% vs. 63.4%). The first pan-European survey investigating ERCP training conditions reveals strong support for structured training and the concentration of training efforts within centers meeting specific quality metrics. Furthermore, this survey exposes the low availability of structured training programs with many trainees practicing at lower-volume centers and 71% of all trainees having little hands-on exposure. These data should motivate to standardize ERCP training conditions further and ultimately improve patient care throughout Europe.

Vade Mecum in ERCP, a roadmap to success: Tips from experts for excelling in ERCP.

Background and study aims Training in endoscopic retrograde cholangiopancreatography (ERCP) is operator-dependent and traditionally, the apprenticeship model, in which experts are considered to be role models, has been adopted for it. The aim of this study was to develop a practical guide compiling tips from experts to help guide trainees to succeed in ERCP. Methods A web-based survey was created to understand the professional development of ERCP experts, the investments they made, the obstacles they overcame, and the quotes that guided their professional life. ERCP experts worldwide were invited to participate. Results Fifty-three experts (of 71; 74.6%) from 24 countries answered the survey. Experts started ERCP training early (average age 31 years; range, 24-52 years) and it often was combined with training for endoscopic ultrasound. A long training period (average 21 months; range, 3-120 months) was needed to achieve competence, frequently in another department, and it was commonly complemented with research in the field (76.5%). "Time and practice" were the most worthwhile investments they made to achieve success. "Sports" were an area outside endoscopy frequently considered to be important to acquire the skills necessary to excel in ERCP. "Lack of dedicated time for training" and "peer competition" were the biggest obstacles the experts faced. Several pieces of advice were given to the experts, such as to be resilient, careful, patient, responsible, and hard-working. "Personal life" was mentioned as an undeniably crucial factor for achieving long-term success that should not be forgotten. Conclusions This survey is the first to provide insight regarding the professional trajectory of renowned ERCP experts worldwide, providing valuable recommendations to help trainees excel in ERCP.

Limited exposure to pancreatic ERCP during advanced endoscopy training impacts competence and performance in independent practice

The impact of competency-based training programs on pancreatic endoscopic retrograde cholangiopancreatography (ERCP) performance remains unclear. This study aimed to describe the learning curves of pancreatic ERCP and subsequent performance during independent practice. This was a multicenter prospective cohort study involving advanced endoscopy trainees (AETs). In the 1st phase, trainees were assessed on every 5th ERCP using the ERCP and EUS Skills Assessment Tool (TEESAT). Cumulative sum (CUSUM) analysis of pancreatic ERCP evaluations was used to establish learning curves. During the 2nd phase (1st year of independent practice), now-graduated participants documented their performance on key ERCP quality indicators. A total of 24 AETs (20 training programs) received sufficient evaluations for CUSUM analysis. Pancreatic ERCP accounted for 14.6% (196/1339) of all ERCPs evaluated with 45% of pancreatic ERCPs carrying a Grade 3 level of complexity. A minority of AETs (16.7%) performed enough pancreatic ERCPs to generate meaningful learning curves with no AETs achieving competence in pancreatic cannulation, sphincterotomy, or stone clearance during Phase 1. In Phase 2, a total of 3620 ERCPs were performed, of which 281 (7.8%) were pancreatic ERCPs. While the overall pancreatic duct cannulation rate was 92.2%, the native papilla pancreatic duct cannulation rate was 85.7%, which was below the recommended 90% threshold. Advanced endoscopy training offers a low level of exposure to pancreatic ERCP, which is mirrored in independent practice, highlighting the inadequate training in pancreatic ERCP. Given the complexity of pancreatic ERCP, novel strategies are warranted to improve training in pancreatic ERCP.

Development and evaluation of artificial organ models for ERCP training in patients with surgically altered anatomies

Endoscopy training models (ETM) using artificial organs are practical, hygienic and comfortable for trainees. However, few models exist for training endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. This training is necessary as the number of bariatric surgeries performed worldwide increases. ETM with human-like anatomy were developed to represent the postoperative anatomy after Billroth II (BII) reconstruction for a standard duodenoscope and the situs of a long-limbed Roux-en-Y (RY) for device-assisted enteroscopy (DAE). In three independent workshops, the models were evaluated by international ERCP experts. In RY model, a simulation for small bowel behavior in endoscopy was created. Thirty-three experts rated the ETM in ERCP expert courses. The BII model was evaluated as suitable for training (school grades 1.36), with a haptic and visual impression rating of 1.73. The RY model was rated 1.50 for training suitability and 2.06 for overall impression. Animal tissue-free ETMs for ERCP in surgically altered anatomy were successfully created. Evaluation by experienced endoscopists indicated that the models are suitable for hands-on ERCP training, including device-assisted endoscopy. It is expected that patient care will improve with appropriate training in advanced procedures.

Endoscopic retrograde cholangiopancreatography training and education.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used to diagnose and treat biliary and pancreatic diseases. It is one of the most technically demanding endoscopic procedures. ERCP training programs must ensure trainees have adequate knowledge of the anatomy and physiology associated with biliopancreatic diseases. The variety of ERCP procedures included in training programs should provide sufficient basic training for novice trainees and advanced training for experienced endoscopists. The main endoscopic procedures should be trained in ascending order of difficulty. Incorporating models capable of simulating various clinical and anatomical conditions could provide an effective means of fulfilling training requirements, although they are not easily available due to expensive facilities and void of standard assessment. Competency assessment is crucial in ERCP training to ensure trainees can independently and safely perform ERCP. Because of the rapid advancement of diagnostic and therapeutic methods, postgraduate training is critical for ERCP practitioners. Once certificates are attained, practitioners are solely responsible for maintaining their competency, credentialing, and quality.

Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

Anatomical endoscopic retrograde cholangiopancreatography simulator using moulded meshed silicone: A novel simulator pilot study.

Endoscopic retrograde cholangio-pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient-based training in ERCP however models to date have been unconvincing. This ERCP simulation model was constructed from moulded meshed silicone by co-designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists. From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009). The simulator showed statistically significant results in face, content, and construct validity. A follow-up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.

A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW

Abstract Background Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated. Purpose To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework Method We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively. Result(s) From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5). Conclusion(s) The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making. Please acknowledge all funding agencies by checking the applicable boxes below CAG Disclosure of Interest None Declared

Prevention of post-ERCP pancreatitis: current strategies and novel perspectives.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.

Review] The Use of Simulation in Endoscopic Retrograde Cholangiopancreatography training: A Literature Review

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopy procedure that has become the gold standard minimally invasive method of diagnosing and treating a vast variety of hepatopancreatobiliary diseases. It is associated with a significantly higher rate and wider range of adverse events compared with standard Upper GI endoscopy, with fewer of these procedures being performed in most centres and with procedure specific equipment and skills that most novice endoscopists will not be familiar with. These issues make training in ERCP challenging. AIMS: This literature review aims to look at the existing information available in the literature on the use of endoscopy simulators in ERCP training to see whether simulation training has a role in ERCP training, the main benefits and drawbacks of endoscopic simulation training, and how simulation training can be integrated into the learning process for achieving competence in ERCP. METHOD: Study searches were conducted in the MEDLINE, EMBASE, CENTRAL/Cochrane Library databases, Web of Science, Google Scholar, LILACS and FINDit. Studies assessing simulation training against traditional training or against other methods of simulation were identified for inclusion in this literature review. Results: Eight studies met the criteria for inclusion in this literature review with five of these being randomised control trials, where the primary outcome was biliary cannulation rates in simulation training against a control group. CONCLUSION: Simulation training has the potential to make trainees more knowledgeable about the basics of ERCP and help develop the technical skills required to perform ERCP competently, as shown by all four RCTs demonstrating that trainees in the simulation group had a statistically higher rate of achieving biliary cannulation against control groups. Endoscopic simulation training should be embedded in ERCP training programmes to act as an important part of the initial development of skills in a safe environment, where trainees can achieve a satisfactory level of proficiency before performing procedures on patients to limit the risk of adverse events and complications. Further trials are required to assess EMS and ECS against traditional methods of learning.

International cross-sectional survey on endoscopic retrograde cholangiopancreatography training by the World Endoscopy Organization.

Endoscopic retrograde cholangiopancreatography (ERCP) has revolutionized the treatment of many pancreaticobiliary conditions. However, little is known about the global practices, training programs, and credentialing of the procedure. The aim of the current study is to address the above questions. This was an international cross-sectional survey conducted between October 2020 and May 2021. Participating countries were requested to complete an online survey on ERCP services and training. Eighty-nine countries responded to the survey. There were significant increases in the proportion of ERCP services provided by the government (P < 0.0001), number of endoscopists per million of population (P < 0.0001), and number of institutions per million of population (P < 0.0001) from low to high human development index (HDI). Eighteen percent of the countries offer the procedure as part of a standard training program, 68.5% do not follow a standardized training curriculum. Risk factors for higher incidence and mortality from pancreatic cancers include higher HDI category, smaller population, a larger number of endoscopists proficient in ERCP, and lower number of institutions providing ERCP training. Countries with very high HDI have four times higher incidence and mortality from pancreatic cancers as compared to those with low HDI. There is still an ongoing need for improving ERCP training in low to very high HDI countries. A structured training program is still lacking in many parts of the world. With increasing incidence and mortality of pancreatic cancers, particularly in high HDI countries, there is a need for further increasing facilities for ERCP training.

ERCP licence in the context of medical practices, legal regulations, medical ethics and patient's rights in our country.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an invasive endoscopic procedure mainly used for hepatobiliary and pancreatic disorders. Although it was first developed by a surgeon, McCune, there is still debate on who can perform this procedure. This problem, which actually needs to be solved within medical ethics, has been brought to the courts, and lawsuits have been filed against general surgeons to prevent them from performing ERCP. The current situation in our country demonstrates that 50-70% of ERCP procedures are performed by general surgeons. In regions where there are not enough gastroenterology specialists, only general surgeons perform this procedure. Today, general surgeons have hundreds of articles on ERCP procedures and studies accepted as international guideline. ERCP procedure -which is in fact a surgical procedure- is included in hepatobiliary surgical procedures in the general surgery core training schedule. General surgeons receive ERCP education in a 6-month challenging program at centers accredited by the Turkish Surgical Society. The problem of ERCP license cannot be solved by legal authorities but by medical, ethical and deontological discussions. Our recommendation here is that the Ministry of Health should associate this procedure with a specific legislation, just like in endoscopy, and establish a specific ERCP training program accepted for license. In this article, the problem of who should perform ERCP was discussed within the framework of legal legislation, medical doctrine and realities of our country.

Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

Background/AimsCholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. MethodsOne hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: “Trainees,” “Consultants group 1” (performed >75 ERCPs per year), and “Consultants group 2” (performed >100 ERCPs per year). ResultsTrainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77–0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74–0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69–0.95). ConclusionsThis investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography.

Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1–2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.

Introduction to the Rule Book of Pancreatobiliary Endoscopy Certification

An endoscopic retrograde cholangiopancreatography (ERCP) procedure requires the highest level of difficulty among endoscopic procedures and the complications related to the procedure is relatively high, and fatal. Training in ERCP requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. Therefore, a system that certifies qualifications through objective and systematic training and examination is needed to improve patient safety and quality of medical services. This manuscript introduces a set of rules that contain all the necessary matters for the certification system of pancreatic and biliary endoscopy.

S999 Impact of Trainee Involvement on the Total Procedural and Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography (ERCP)

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) training guidelines are evolving to be more competency-based in the absence of a standardized curriculum. We aimed to determine the effect of trainee involvement and center volume influences the ERCP scope time (ST), total procedural time (TPT), and fluoroscopy time (FT). Methods: Patients from Clinical Outcome Research Initiative National Endoscopic Database CORI-NED (2009-2014) who underwent ERCP were stratified based on the trainee participation (trainee participated vs. not participated), center volume (ERCPs performed >200/year-high volume (HV), 100-200/ year- intermediate volume (IV), < 100 per year-low volume (LV)). ST was defined as the time interval between ERCP scope insertion and withdrawal, TPT as the time interval requiring ERCP intervention, and FT as the time interval fluoroscopy activated. The time variables were compared against trainee involvement and ERCP center volume using the Kruskal-Wallis test and significance level defined for a p-value < 0.05 (Table 1). Results: A total of 13,855 ERCPs, comprising trainee participation (n= 6488) and non-participation (n=7367) were performed at HV (n=2220), IV (n=5062) and LV (n=6573) centers respectively. Trainee participation vs. non-participation significantly increased ST [31(20-40) versus 23.5(16-38.5), p< 0.014, Fig 1a], TPT [28 (24-48) vs. 24 (17.75-41.25), p< 0.00, Fig 1b]. However, FT was unaffected by trainee participation or non-participation (Fig 1c). HV vs. LV ERCP centers were significantly associated with prolonged ST [36(22.5-58) versus 24(16-39), p< 0.001)], TPT [36(25.5-61) vs. 28(18-42), p< 0.001)] and FT [6(3.5-9) vs. 2(1-2), p< 0.001)], respectively. HV vs. IV ERCP centers were significantly associated with prolonged ST [36(22.5-58) versus 31(16.5-46), p< 0.001)]. HV vs. IV centers were not associated with prolonged TPT [36(25.5-61) vs. 35(28-58.5), p=NS)] and FT was only marginally prolonged to statistical significance [6(3.5-9) vs. 5(2.5-11), p=0.03)], (Fig 1 d,e,f). Conclusion: Trainee involvement in ERCP interventions is associated with significantly longer scope time, total procedural time, and fluoroscopy time. Differences were similar for scope time and fluoroscopy time comparing HV centers with IV centers, but no difference was noted for total procedure time. It is anticipated that these findings will have a profound impact on structuring ERCP training and resource utilization.Table 1.: Pair-wise comparisons of scope time, total procedure time, and fluoroscopy time (minutes) across independent variables (trainee participation and center volume). DF#- degrees of freedom, IQR*-interquartile range, H (c2 chi-square statistic) for Kruskal Wallis test, NS-not significant.Figure 1.: Comparison of the various intraprocedural time intervals during ERCP with trainee participation and procedure volume.

Simulators for endoscopic retrograde cholangiopancreatography training: systematic review and meta-analysis.

Simulators for endoscopic retrograde cholangiopancreatography training: systematic review and meta-analysis.

Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2: Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee's procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3: Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4: The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.